Respiratory Devices to Manage Obstructive Lung DiseaseVirtual Patient Tour Key Points and Pitfalls

COMMON THEMES FOR INHALERS

Metered-dose Inhalers ___________________________ § Generally should be used with a valved holding chamber § Require priming § Must always be held upright and shaken for at least 5 seconds § Require a slow, deep breath § Redihaler is only breath-actuated MDI & should NEVER be shaken § Wait 30-60 seconds between doses

Slow Mist Inhaler ________________________________ § Requires priming § Requires a slow, deep breath § Wait 30-60 seconds between doses

Dry Powder Inhalers______________________________ § All DPIs should be kept dry – without moisture § Only prime Flexhaler ONCE, other DPIs should NEVER be primed § Never – ever – ever shake a DPI device (powder will spill out) § Do not breathe into the device or open before you are ready to use (moisture in breath

or the air will clump and gum up the powder) § Avoid covering the air vents with lips or fingers § MUST inhale with a forceful, fast, and deep breath for each dose with adequate inspira-

tory force to deliver the powder deep into the lungs § Should hold breath for 3-4 or up to 10 seconds for all but the Flexhaler (whose package

insert doesn’t specify about breath-hold). § Should NEVER use a valved holding chamber with any DPI

Nebulizers: Main Types = Jet & Electronic ___________Jet Nebulizers

§ Three general types of jet nebulizers: (1) Standard jet (2) Breath-enhanced jet (3) Breath-actuated jet

§ Require compressor or power pack § Generally require 2-10 L/min of pressurized gas § Treatment times vary from 15-25 minutes § Generally larger, but lower in cost than the vibrating mesh nebulizers § Standard jet nebulizers only deliver about 20% of aerosol to lungs

Electronic § There are two main types of electronic

nebulizers, but only the mesh nebulizers are used in clinical practice for nebulizing medications:

(1) Ultrasonic (used currently for sputum induction)

(2) Vibrating mesh (eg, Innospire Go, Lamira, Magnair...)

§ Small, portable, quiet, and deliver medications quickly and efficiently

§ Wafer thin, metal alloy mesh about 5-10 mm in diameter with 1,000-7,000 laser-drilled tapered, funnel-shaped holes: easily clogged

§ CLEAN HANDS & CLEAN NEBULIZER are key!!

Supported in part by an educational grant from GlaxoSmithKline. Supported in part by an independent education grant from Mylan Specialty L.P. and Theravance Biopharma US, Inc. Supported in part by an independent medical education grant from Sunovion Pharmaceuticals Inc. Supported in part through an independent educational grant from Teva Pharmaceuticals.

DRY POWDER INHALERS (SINGLE)

HandiHaler® ____________________________________ § Keep capsules in blister pack until just prior to use

(moisture causes powder to clump) § Open the dust cap and the white mouthpiece § Place capsule in the well § Press and release the green piercing button once § Exhale away from the device § Seal lips around mouthpiece (do not block air vents) § Breathe in forcefully and deeply – you should hear a

rattling noise § Hold your breath for up to 10 seconds § Exhale away from the device § Then inhale a second time (repeating steps above with the same capsule - do not pierce

the capsule again) § Discard the capsule in the trash without touching it

Neohaler® ______________________________________ § Keep capsules in blister pack until just prior to use (moisture

causes powder to clump) § Remove the dust cap and open the white mouthpiece § Place capsule in the well § Press the two piercing buttons on the sides once, then release § Exhale away from the device § Hold the device with buttons on the sides (not up and down) § Seal lips around mouthpiece (do not block air vents) § Breathe in rapidly, but steadily and deeply, and you should

hear a whirling noise § Hold your breath for up to 10 seconds § Exhale away from the device § Open the mouthpiece and, if there is still medicine in the capsule, then inhale a second

time (repeating steps above with the same capsule - do not pierce the capsule again)

Podhaler® ___________________

§ Keep capsules in blister pack until just prior to use (moisture causes powder to clump) – remove only one at a time

§ Remove the Podhaler lid (dust cover) and remove the mouthpiece

§ Peel back foil on the blister pack to expose one capsule

§ Place the capsule in the capsule chamber (NOT in the mouthpiece)

§ Replace the mouthpiece (being careful not to over tighten) § Remove the Podhaler from the base and hold upside down § Press the blue button completely to pierce the capsule, then release § Exhale away from the device § Seal lips around mouthpiece and breathe in rapidly, but steadily § Hold breath for about 5 seconds then exhale away from the device § Repeat inhalation steps (total of two inhalations per capsule and usual dose requires

four capsules

Digihaler™ ______________________________________ § Hold the Digihaler upright and open the cap to load the dose § Holding away from your mouth, breathe out gently, but completely § Seal lips around mouthpiece and breathe in quickly and deeply

through your mouth until you take a full, deep breath § Move the device away from your mouth § Hold your breath for up to 10 seconds or as long as possible § Then breathe out slowly § Slide the cover back over the mouthpiece to close the device

Diskus® _________________________________________ § Hold the Diskus parallel to the floor § Use the thumb grip to slide the cover to expose the

mouthpiece § Slide the lever away from you to load the medicine § Holding the Diskus with both hands (like a hamburger)

but away from your mouth, breathe out gently, but completely

§ Seal lips around mouthpiece and breathe in quickly and deeply through your mouth until you take a full, deep breath

§ Move the device away from your mouth § Hold your breath for up to 10 seconds or as long as possible § Then breathe out slowly § Slide the cover back over the mouthpiece to close the device

Ellipta® _________________________________________ § Hold the Ellipta upright and slide the cover down to expose

the mouthpiece and air vents and to load the medicine § Holding the Ellipta with both hands (like a hamburger) but

away from your mouth, breathe out gently, but completely § Then seal lips around mouthpiece, but do not block air

vents § Breathe in one full, long steady breath through your mouth § Move the device away from your mouth § Hold your breath at least 3-4 seconds or as long as possible § Then breathe out slowly § Slide the cover back over the mouthpiece to close the device

Flexhaler® ______________________________________ § Prime the device once before first use § Hold upright and remove the cap to expose the mouthpiece § Turn the base all the way in one direction and then in the opposite

direction until you hear a click to load the medicine § Holding away from your mouth, breathe out gently, but completely § Then seal lips around mouthpiece, but do not block the air vents § Take a forceful, full, and deep breath through your mouth § Move the device away from your mouth and breathe out slowly § If a second dose is needed, turn the base in both directions as above

to load the next dose and then repeat the breathing steps

Inhub™ _________________________________________ § Hold the Inhub upright § Use the thumb grip to slide the cover to expose the

mouthpiece § Slide the lever down to load the medicine § Holding the Inhub upright and away from your mouth,

breathe out gently, but completely § Seal lips around mouthpiece and breathe in quickly and

deeply through your mouth until you take a full, deep breath

§ Move the device away from your mouth § Hold your breath for up to 10 seconds or as long as possible § Then breathe out slowly § Slide the cover back over the mouthpiece to close the device

Pressair® ________________________________________ § Hold the Pressair upright and remove the dust cap § Control window indicator should be red § Press the button all the way down and release

completely § Make sure the indicator in the control window

turns green § Holding the device upright and away from your

mouth, breathe out gently, but completely § Seal lips around mouthpiece and take a strong, deep breath through your mouth and

you may hear a click § Move the device away from your mouth § Hold your breath for up to 10 seconds or as long as possible § Then breathe out slowly and be sure the indicator is red § Replace the dust cover

Respiclick® ______________________________________ § Hold the Respiclick upright and open the cap to

load the dose § Holding away from your mouth, breathe out

gently, but completely § Seal lips around mouthpiece and breathe in quickly and deeply

through your mouth until you take a full, deep breath § Move the device away from your mouth § Hold your breath for up to 10 seconds or as long as possible § Then breathe out slowly § Slide the cover back over the mouthpiece to close the device

Twisthaler® _____________________________________ § Hold upright, remove the cap to expose mouthpiece and load dose § Holding away from your mouth, breathe out gently, but completely § Then seal lips around mouthpiece, but do not block the air vents § Take in a fast deep breath through your mouth § Move the device away from your mouth and hold your breathe for up

to 10 seconds § Breathe out slowly and replace the lid § If a second dose is needed, remove the cap again and repeat the

breathing steps

DRY POWDER INHALERS (MULTI)

Redihaler™ (Breath-Actuated MDI) _________________ § Open the cap § Do NOT shake (medicine may spill out) § Breathe out slowly away from device § Seal lips around mouthpiece § Inhale deeply through the mouth § Hold breath for up to 10 seconds § Breathe out away from device § Close the cap until clicks § Wait 30-60 seconds § Repeat steps for next dose

Respimat® (Slow Mist Inhaler) _____________________ § Load the cartridge by pressing down on a firm surface. § Prime the device before the first dose § Remember the steps: “TOP” § Turn the clear base (in the directions of the arrow). § Open the cap, and close your lips around the mouthpiece. § Press the dose-release button and inhale slowly § Do not block the side air vents § Point the device away from your face/eyes before opening the cap § Wait 30-60 seconds § Repeat steps for next dose

AEROSOL DEVICES

Metered-dose Inhaler (MDI) _______________________ § Most effective when used with valved holding chamber § Open the cap § Inspect (ensure no foreign objects) § Shake for at least 5 seconds § Breathe out slowly away from device § Seal lips around mouthpiece § Start inhaling (through mouth) and actuate dose of medication

while continuing to breathe in slowly and deeply § Hold breath for up to 10 seconds § Breathe out away from device § Wait 30-60 seconds § Repeat steps for next dose (if needed)

MDI With Valved Holding Chamber (VHC) ___________ § Perform same steps as above, but after shaking MDI, attach to VHC § Also requires a slow deep breath § If VHC whistles or makes any noise – you are breathing in too quickly